group health quote

Group Health Quote

Business Name:

Contact Name:

Contact Title:

Address:

City/Zip:

Phone:

Email:

Current Insurance?

If yes:

Carrier:

Renewal Date:

Current Ins.Plan:
(Traditional Plan with Copays or HSA Plan?)

Deductible:

Co-ins.?

Out-of-Pocket Max?

Copays?

Employer Contribution %:

Section 125 in Place?

How many full-time eligible employees?

Please note:
Policies are subject to medical underwriting. All information provided on this form is strictly confidential.

Please Complete Census below, showing ALL Full-time employees. If someone has coverage elsewhere (on spouse's plan or has individual coverage, please indicate:
Date of Birth	Gender	Zip Code	Type of Coverage (Emp, Emp/spouse, Emp/child(ren), Family)

Comments?

Please note that completion of the following request for information does not constitute the purchase of insurance. No coverage may be added, changed or bound as a result of submitting this request for information or quotation insurance. All coverage must be confirmed by the agency in writing subject to an acceptable signed application meeting the underwriting guidelines of the insurance company.